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Why the @#* does my knee hurt (again)? Understanding Overuse Injuries.

Why the @#* does my knee hurt (again)? Understanding Overuse Injuries.

Scot JurekOveruse / overload injuries are the mother-in-law of all running injuries. They show up unannounced at your door one day and decide to move in for an indefinite amount of time. It is very hard to live with them and even harder to get rid of them. The best way to treat them is to avoid them.

When faced with a nagging overuse running injury, we all have our own beliefs as to the cause of the injury. When you consult some healthcare professionals, they might propose several theories as to what caused the injury. Reasons given can range from “muscle imbalances”, a “weak core” to “you were born with the wrong feet” or as I was told “it’s your scoliosis that causes your one leg to be longer than the other that causes your thigh to rotate inwards that causes your knee pain”. For some reason we were taught that biomechanical imbalances are causing our injuries, but this is only true for a small group of runners. Let’s face it, no one is normal and very few people have perfect biomechanics. So I had to ask two questions: 1. I cannot change my leg-length, scoliosis or flat feet, so should I just give up on running?  2. I was born with these “faults” and I have been a runner for 20 years, why are they only now becoming a problem? So maybe the answer lies elsewhere?

Fortunately the evidence shows us that there is little correlation between our lower-limb or spine abnormalities and risk for overuse running injuries. The evidence is however suggesting that up to 70% of running injuries are caused by training error, most often a rapid change in running distance or intensity. Sounds familiar? We’ve all done too much at some point and paid the price for overtraining. To better understand how training error leads to injury, we first need to understand how our bodies respond to training.

Running consists of a series of repeated mechanical loads known as foot strikes. Most runners will have 500 to 600 foot strikes per kilometer. With every foot strike and push-off, loads and forces are generated and absorbed by the bones, muscles, tendons and ligaments, stressing the tissues that stabilizes and propels us during running. The more you run, the more stress you apply to these tissues. After each training session, our bodies go through a process of recovery to allow our bones, tendons, muscles and ligaments to change and grow stronger. We call this adaptation. To allow for recovery and adaptation, a period of rest is required before we train again.  The opposite is also possible where insufficient load and prolonged rest can cause detraining to occur.three-things-infog-v2If you balance training with rest, the body will continue to adapt and grow stronger after each cycle of training and adaptation, if you over-train or under-recover by neglecting to rest enough before training again, the stresses will accumulate and lead to breakdown of tissues that eventually leads to stress fractures, tendon overload, tendinopathies etc. Introducing new external factors to your running, without allowing time to adapt to these new loads, be it new running shoes, running form or transitioning from road to trail, will also lead you down a path to injury.

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The quote below sums it up:

“It is logical to assume that the musculoskeletal system of runners could recover and repair itself rapidly enough from relatively low levels of impact forces, but some threshold level of impact force, repeated for some threshold level of repetitions would result in injury. It is also likely that a runner who has maintained a training program in which these threshold levels have not been exceeded would have the various related structures remodelled in such a manner as to become more resistant to injury.” Hreljac et al. (2000)

Once you understand how to balance training loads and rest, you realize training can be used to prevent and treat injury. It’s all about finding that training “sweet spot” where the magic happens.

Principles for Healthy Runners:

TRAIN. REST. RECOVER. ADAPT. REPEAT

  1. Manage your training loads. Follow a program to slowly increase your body’s ability toTime to adapt blue round grungy vintage isolated rubber stamp tolerate load. This is where a good coach might come in. Most runners still follow the 10% rule, but we are all an experiment of one, adaptation and load tolerance will be different for each of us, some runners will be able to do more than 10% and other runners will find they need to do even less. Strength training plays a vital role in increasing the body’s ability to tolerate load and prevent breakdown.
  2. Rest and Recover. Recovery demands discipline. You cannot get around time and there are no substitutes for sleep and good nutrition. I am a firm believer in no less than 2 off days a week, where off means off (OMO).

Principles for Injured Runners:

MODIFIED TRAINING. REST. RECOVER. ADAPT. REPEAT.

  1. Modify your training loads. Complete rest is not always the solution to overuse injuries, we need to decrease the training load to a point where it doesn’t worsen symptoms but still do enough to stimulate change in the injured structures. Training can produce pain but symptoms shouldn’t be worse after you finish training.
  2. Increase the injured tissues’ ability to tolerate load. Progressive strength training is necessary when treating any overuse injury, e.g. modified calf raises for Achilles tendinopathy. After an initial period of rest, stress fractures will need a progressive increase in weight bearing to stimulate bone growth.
  3. Modify other external loads if it contributes to overloading: poor running form, new or improper running shoes etc. To piece together where a running injury is coming from we need to understand all aspects of your training, not only the running loads, but also your work-environment, hobbies and cross-training as all of these can contribute to your overall load or lack of recovery.

Your physiotherapist can help you problem-solve and structure a modified training program to get you back to full recovery.

To bring us back to the question of what causes overuse running injuries? I recently had a conversation about running injuries with a fellow therapist and running coach from Austin, Texas and he put it quite bluntly: “Well Tarrin, if runners asks me what causes running injuries I give them a straight answer: RUNNING.”

The answers are not always that simple, but Sherlock Holmes did say: “There is nothing more deceptive than an obvious fact.”

Allow the way you train to become your best defense against injury.

Happy running.

Tarrin van Niekerk

Physiotherapist and Blogger at Running Clinic & UltraRunner ZA
I am a Physiotherapist with a special interest in running injury prevention.I enjoy running in all its forms; but I am happiest in the mountains.I believe in empowering runners by teaching them self-management and injury-prevention strategies. You have all the answers as to why you have pain, I just know how to ask the right questions.I am a fan of common sense and the best current available evidence.

You can find me at:
tarrin@runningclinic.co.za
071 685 2235
Practice: Lifestyle Management Park
Unit 4, Second Floor, Suite 224
Clifton Ave, Lyttelton, Centurion
012 664 6128

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About The Author

I am a Physiotherapist with a special interest in running injury prevention. I enjoy running in all its forms; but I am happiest in the mountains. I believe in empowering runners by teaching them self-management and injury-prevention strategies. You have all the answers as to why you have pain, I just know how to ask the right questions. I am a fan of common sense and the best current available evidence. You can find me at: tarrin@runningclinic.co.za 071 685 2235 Practice: Lifestyle Management Park Unit 4, Second Floor, Suite 224 Clifton Ave, Lyttelton, Centurion 012 664 6128

1 Comment

  1. Great article, thanks!

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